A varicocele is a condition characterized by enlarged and twisted veins in the scrotum, similar to varicose veins. It occurs when the valves in the testicular veins fail, causing blood to flow backward and pool, leading to congestion and swelling. Varicoceles are common, affecting 1 in every 5 men. Varicoceles can happen at any age, and some experts believe that the presence of varicoceles can occur from birth onwards. They often form and are detected during puberty, when blood flow to the genitals increases, and in these cases they can prevent proper growth and development of the testicles.
Some patients may not experience any pain symptoms. However, varicoceles are major causes of low sperm production and decreased sperm quality, which eventually lead to infertility in 40% of all men who have problems fathering their first child. They could inhibit the regular development of testicles and instead cause them to shrink.
- Varying pain (sharp to dull) in the scrotum and testicles
- Increased pain with standing or physical exertion, especially over long periods of time
- Pain relief upon lying down
- A lump/swelling in one of your testicles
- Visibly engorged or twisted veins in the scrotum (“bag of worms”)
- Testicular atrophy
Varicoceles can occur in men at any age, but are often formed and detected during puberty when blood flow to the genitals increases.
Varicoceles are commonly discovered through self-examination or routine doctor’s examinations. Physical examinations and scrotal ultrasound can confirm the presence of varicoceles.
Some varicoceles do not require any further treatment as they can be asymptomatic. However, if you happen to have a varicocele that is very painful, causes swelling in the scrotum, causes testicular atrophy (shrinking of the testicles) or you are considering assisted reproductive techniques, you may want to consider treatment of the varicocele. Varicoceles might keep the temperature of the testicle too high, affecting the function, motility, and formation of sperm. The earlier you begin to treat this condition, the better your chances of improving your sperm production and quality.
Treatment options:
A varicocelectomy is a same-day surgery that is done in a hospital. There are multiple ways to perform a varicocelectomy, and all of them involve blocking the blood flow in the veins of the spermatic cord, and will be performed under general anaesthesia.
Microscopic varicocelectomy: This involves a urologist ligating (clamping or tying) all small veins through a 1cm incision above the scrotum, which takes 2-3 hours to complete. Blood is then able to flow regularly, avoiding abnormal veins.
Laparoscopic varicocelectomy: This involves the urologist inserting thin tubes into the abdomen to ligate the veins. This procedure takes only 30-40 minutes to complete. For both kinds of varicocelectomy, healing time (around 1 week) and pain level are around the same, and the procedures are generally safe, with post-surgical complications being very rare.
Complications although rare, include:
The varicocele remaining (persisting) or coming back (recurring)
Fluid forming around the testicle (hydrocele)
Injury to the testicular artery
As an alternative, a vein or groin access puncture may be used to perform percutaneous embolization, a minimally invasive procedure. During this treatment, all veins leading to the varicocele are located and the cause of the problem is viewed using X-ray fluoroscopy, which also guides the catheter. In order to stop the blood flow to the varicocele, iron coils and an embolic agent are inserted into the irregular blood arteries supplying it during the embolization procedure. This can be done under light sedation or with a local anesthetic, and it takes anywhere from 45 minutes to an hour to complete.
Following percutaneous embolization, you may leave the same day of the procedure and resume your regular activities in a week. Furthermore, the operation is safe, effective, and causes very little discomfort. Although there are situations in which embolization is preferable to surgery, the recurrence rate following embolization is same to that following surgery. Treatment for varicocele should undoubtedly be considered in conjunction with other fertility therapy options if your goal is to increase your fertility.
Case Study 1
Patient presented with recurrent left scrotal pain and heaviness. Semen analysis also showed low sperm count.
Access was created through the right common femoral vein, and a pelvic angiogram was conducted, along with a pelvic and left renal venogram. The left renal veins and gonadal veins were then cannulated, and embolisation of the gonadal vein and varicocele was performed with metallic coils thus blocking it off.
Fig 1: Pre and post embolisation images of gonadal vein and varicocele.
Patient needs sympathetic relief 24 hours post and repeat semen analysis showed much improved sperm count.
